NUR 425 Exam 3: Medical Surgical V3 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with ARDS is placed on mechanical ventilation with high PEEP. Which assessment finding is
most concerning to the nurse?
A. Coarse crackles at the lung bases
B. SpO2 of 93% on 60% FiO2
C. Respiratory rate of 22 breaths per minute
D. Blood pressure 88/46 mmHg
Ans: D
Explanation: High levels of PEEP increase intrathoracic pressure which can significantly reduce venous
return to the heart. This reduction in preload leads to a decrease in cardiac output and subsequent
hypotension. The nurse must monitor hemodynamic stability closely when PEEP is elevated above 10 cm
H2O. A blood pressure of 88/46 suggests compromised perfusion that requires immediate intervention.
Other findings like crackles are expected in ARDS and do not represent the acute risk posed by
hemodynamic collapse.
2. The nurse is caring for a patient in the resuscitation phase of a 40% TBSA burn. Which finding indicates
adequate fluid resuscitation?
A. Heart rate of 120 beats per minute
B. CVP of 2 mmHg
C. Systolic blood pressure of 95 mmHg
D. Urine output of 0.5 mL/kg/hr
,Ans: D
Explanation: Urine output is the most reliable non-invasive indicator of organ perfusion during burn
resuscitation. For an adult, a target of 0.5 to 1.0 mL/kg/hr is generally standard to ensure renal health.
While heart rate and blood pressure are monitored, they can be influenced by pain and stress in burn
patients. A urine output meeting this threshold suggests that the fluid volume is sufficient to maintain
vital organ function. Failure to meet this goal may necessitate an increase in the infusion rate based on
the Parkland formula.
3. A patient in the ICU is suspected of having Septic Shock. Which lab result should the nurse prioritize
communicating to the provider?
A. Lactate level of 4.2 mmol/L
B. WBC count of 15,000/mm3
C. Glucose level of 160 mg/dL
D. Hemoglobin of 11 g/dL
Ans: A
Explanation: Serum lactate is a critical biomarker used to identify tissue hypoxia and cellular
dysfunction in shock states. A level greater than 2 mmol/L indicates significant anaerobic metabolism
and is a predictor of poor outcomes. The Surviving Sepsis Campaign emphasizes rapid identification and
treatment of elevated lactate levels. While WBC and glucose are important, they are less specific to the
immediate severity of shock than lactate. Communicating this result allows for the timely initiation of
aggressive fluid resuscitation and antibiotic therapy.
4. A patient with a T6 spinal cord injury reports a sudden severe headache and has a BP of 210/110. What is
the nurse’s first action?
A. Administer PRN hydralazine
, B. Check the patient’s bladder for distention
C. Notify the rapid response team
D. Place the patient in a high-Fowler’s position
Ans: D
Explanation: Autonomic dysreflexia is a medical emergency characterized by life-threatening
hypertension in patients with spinal injuries above T6. The immediate priority is to sit the patient up to
utilize orthostatic changes to lower blood pressure. Once the patient is upright, the nurse should
investigate and remove the noxious stimuli, such as a full bladder or impacted bowel. Medication may be
necessary if the pressure remains high, but positioning is the fastest intervention. Prompt action is
required to prevent complications like stroke or retinal hemorrhage.
5. Which mechanical ventilator alarm should the nurse troubleshoot first for a patient who is suddenly
agitated?
A. Apnea alarm
B. Low pressure alarm
C. High pressure alarm
D. Low minute volume alarm
Ans: C
Explanation: High pressure alarms are frequently triggered when the patient is biting the endotracheal
tube or coughing. Agitation often leads to ‘fighting the ventilator,’ which increases airway resistance and
triggers the high pressure limit. The nurse should assess the patient’s respiratory status and provide
sedation or a bite block if necessary. Low pressure alarms usually indicate a disconnection in the circuit,
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient with ARDS is placed on mechanical ventilation with high PEEP. Which assessment finding is
most concerning to the nurse?
A. Coarse crackles at the lung bases
B. SpO2 of 93% on 60% FiO2
C. Respiratory rate of 22 breaths per minute
D. Blood pressure 88/46 mmHg
Ans: D
Explanation: High levels of PEEP increase intrathoracic pressure which can significantly reduce venous
return to the heart. This reduction in preload leads to a decrease in cardiac output and subsequent
hypotension. The nurse must monitor hemodynamic stability closely when PEEP is elevated above 10 cm
H2O. A blood pressure of 88/46 suggests compromised perfusion that requires immediate intervention.
Other findings like crackles are expected in ARDS and do not represent the acute risk posed by
hemodynamic collapse.
2. The nurse is caring for a patient in the resuscitation phase of a 40% TBSA burn. Which finding indicates
adequate fluid resuscitation?
A. Heart rate of 120 beats per minute
B. CVP of 2 mmHg
C. Systolic blood pressure of 95 mmHg
D. Urine output of 0.5 mL/kg/hr
,Ans: D
Explanation: Urine output is the most reliable non-invasive indicator of organ perfusion during burn
resuscitation. For an adult, a target of 0.5 to 1.0 mL/kg/hr is generally standard to ensure renal health.
While heart rate and blood pressure are monitored, they can be influenced by pain and stress in burn
patients. A urine output meeting this threshold suggests that the fluid volume is sufficient to maintain
vital organ function. Failure to meet this goal may necessitate an increase in the infusion rate based on
the Parkland formula.
3. A patient in the ICU is suspected of having Septic Shock. Which lab result should the nurse prioritize
communicating to the provider?
A. Lactate level of 4.2 mmol/L
B. WBC count of 15,000/mm3
C. Glucose level of 160 mg/dL
D. Hemoglobin of 11 g/dL
Ans: A
Explanation: Serum lactate is a critical biomarker used to identify tissue hypoxia and cellular
dysfunction in shock states. A level greater than 2 mmol/L indicates significant anaerobic metabolism
and is a predictor of poor outcomes. The Surviving Sepsis Campaign emphasizes rapid identification and
treatment of elevated lactate levels. While WBC and glucose are important, they are less specific to the
immediate severity of shock than lactate. Communicating this result allows for the timely initiation of
aggressive fluid resuscitation and antibiotic therapy.
4. A patient with a T6 spinal cord injury reports a sudden severe headache and has a BP of 210/110. What is
the nurse’s first action?
A. Administer PRN hydralazine
, B. Check the patient’s bladder for distention
C. Notify the rapid response team
D. Place the patient in a high-Fowler’s position
Ans: D
Explanation: Autonomic dysreflexia is a medical emergency characterized by life-threatening
hypertension in patients with spinal injuries above T6. The immediate priority is to sit the patient up to
utilize orthostatic changes to lower blood pressure. Once the patient is upright, the nurse should
investigate and remove the noxious stimuli, such as a full bladder or impacted bowel. Medication may be
necessary if the pressure remains high, but positioning is the fastest intervention. Prompt action is
required to prevent complications like stroke or retinal hemorrhage.
5. Which mechanical ventilator alarm should the nurse troubleshoot first for a patient who is suddenly
agitated?
A. Apnea alarm
B. Low pressure alarm
C. High pressure alarm
D. Low minute volume alarm
Ans: C
Explanation: High pressure alarms are frequently triggered when the patient is biting the endotracheal
tube or coughing. Agitation often leads to ‘fighting the ventilator,’ which increases airway resistance and
triggers the high pressure limit. The nurse should assess the patient’s respiratory status and provide
sedation or a bite block if necessary. Low pressure alarms usually indicate a disconnection in the circuit,
